Identifying high-quality bariatric surgery centers: hospital volume or risk-adjusted outcomes?

Volume-outcome relationships for Roux-en-Y gastric bypass patients in the sleeve gastrectomy era

BACKGROUND

Sleeve gastrectomy is now the most common bariatric operation performed. With lower volumes of Roux-en-Y gastric bypass (RYGB), it is unclear whether decreasing surgeon experience has led to worsening outcomes for this procedure.

METHODS

We used State Inpatient Databases from Florida, Iowa, New York, and Washington. Bariatric surgeons were designated as those who performed ten or more bariatric procedures yearly. Patients who had RYGB were included in our analysis. Using multi-level logistic regression, we examined whether surgeon average yearly RYGB volume was associated with RYGB patient 30-day complications, reoperations, and readmissions and 1-year revisions and readmissions.

RESULTS

From 2013 to 2017 there were 27,714 patients who underwent laparoscopic RYGB by 311 surgeons. Median surgeon volume was 77 RYGBs per year. The distribution was 10 bypasses yearly at the 5th percentile, 16 bypasses at the 10th percentile, 38 bypasses at the 25th percentile, and 133 bypasses at the 75th percentile. Multi-level regression revealed that patients of surgeons with lower RYGB volumes had small but statistically significant increased risks of 30-day complications and 1-year readmissions. At 30 days, risk for any complication was 6.71%, 6.43%, and 5.55% at 10, 38, and 133 bypasses per year, respectively (p = 0.01). Risk for readmission at 1 year was 13.90%, 13.67%, and 12.90% at 10, 38, and 133 bypasses per year, respectively (p = 0.099). Of note, volume associations with complications and reoperations due to hemorrhage and leak were not statistically significant. There was also no significant association with revisions.

CONCLUSION

This is the first study to examine the association of surgeon RYGB volume with patient outcomes as the national experience with RYGB diminishes. Overall, surgeon RYGB volume does not appear to have a large effect on patient outcomes. Thus, patients can safely pursue RYGB in this early phase of the sleeve gastrectomy era.

A Hub and Spoke Learning Program in Bariatric Surgery in a Small Region of Italy

Background

Metabolic and bariatric surgery (BS) are considered life-changing and life-saving treatments for obese patients. The Italian Society of Obesity Surgery (SICOB) requires at least 25 operations per year to achieve the standard of care in the field. Despite the increasing need to treat obese patients, some small southern regions of Italy, such as Molise, do not have enough experience in bariatric procedures to be allowed to perform them. Therefore, our aim was to run a Hub and Spoke Program with a referral center in BS to treat obese patients and provide a proper learning curve in BS in Molise.

Methods

In 2020, the “A. Cardarelli Hospital” in Campobasso, Molise, started a formal “Learning Model of Hub and Spoke Collaboration” with the Hub center “Ospedale Del Mare”, Naples. A multidisciplinary approach was achieved. Patients were supervised and operated under the supervision and tutoring of the referral center. We retrospectively reviewed our prospectively collected database from February 2020 to August 2021 in order to analyze the safety and effectiveness of our learning program.

Results

In total, 13 (3 men and 10 women) patients underwent BS with the mean age of 47.08 years and a presurgery BMI of 41.79. Seven (53.84%) patients were the American Society of Anesthesiologist (ASA) II, and 6 (46.16%) patients were ASA III. Twelve (92.31%) procedures were laparoscopic sleeve gastrectomies, 1 (7.69%) patient underwent endoscopic BioEnterics Intragastric Balloon (BIB) placement. One (8.33%) sleeve gastrectomy was associated to gastric band removal. Mean surgical time was 110.14 ± 23.54 min. The mean length of stay was 4.07 ± 2.40 days. No Clavien-Dindo ≥ III and mortality were reported. The follow-up program showed a mean decrease of 11.82 in terms of body mass index (BMI) value. The last 5 procedures were performed by the whole equips from “A. Cardarelli” under external tutoring without any impact on complication rate.

Conclusion

The setup of a proper Hub and Spoke Program may allow to perform BS to provide the standard of care. This approach may reduce health costs and related patient migration.

Trends in Surgical Volume in the Military Health System-A Potential Threat to Mission Readiness

INTRODUCTION

The Military Health System (MHS) is tasked with a dual mission both to provide medical services for covered patients and to ensure that its active duty medical personnel maintain readiness for deployment. Knowledge, skills, and attitudes (KSA) is a metric evaluating the transferrable skills incorporated into a given surgery or medical procedure that are most relevant for surgeons deployed to a theatre of war. Procedures carrying a high KSA value are those utilizing skills with high relevance for maintaining deployment readiness. Given ongoing concerns regarding surgical volumes at MTFs and the potential adverse impact on military surgeon mission readiness were high-value surgeries to be lost to the civilian sector, we evaluated trends in the setting of high-value surgeries for beneficiaries within the MHS.

METHODS

We retrospectively analyzed inpatient admissions data from MTFs and TRICARE claims data from civilian hospitals, 2005-2019, to identify TRICARE-covered patients covered under "purchased care" (referred to civilian facilities) or receiving "direct care" (undergoing treatment at MTFs) and undergoing seven high-value/high-KSA surgeries: colectomy, pancreatectomy, hepatectomy, open carotid endarterectomy, abdominal aortic aneurysm (AAA) repair, esophagectomy, and coronary artery bypass grafting (CABG). Overall and procedure-specific counts were captured, MTFs were categorized into quartiles by volume, and independence between trends was tested with a Cochran-Armitage test, hypothesizing that the proportion of cases referred for purchased care was increasing.

RESULTS

We captured 292,411 cases, including 7,653 pancreatectomies, 4,177 hepatectomies, 3,815 esophagectomies, 112,684 colectomies, 92,161 CABGs, 26,893 AAA repairs, and 45,028 carotid endarterectomies. The majority of cases included were referred for purchased care (90.3%), with the proportion of cases referred increasing over the study period (P < .01). By procedure, all cases except AAA repairs were increasingly referred for treatment over the study period (all P < .01, except esophagectomy P = .04). On examining volume, we found that even the highest-volume-quartile MTFs performed a median of less than one esophagectomy, hepatectomy, or pancreatectomy per month. The only included procedure performed once a month or more at the majority of MTFs was CABG.

CONCLUSION

On examining volume and referral trends for high-value surgeries within the MHS, we found low surgical volumes at the vast majority of included MTFs and an increasing proportion of cases referred to civilian hospitals over the last 15 years. Our findings illustrate missed opportunities for maintaining the mission readiness of military surgical personnel. Prioritizing the recapture of lost surgical volume may improve the surgical teams' mission readiness.

Reoperation Incidence and Severity Within 6 Months After Bariatric Surgery: a Propensity-Matched Study from Nationwide Data

BACKGROUND

Data about incidence and severity of reoperations up to 6 months after bariatric surgery are currently limited. The aim of this cohort study was to evaluate the incidence and severity of reoperations after initial bariatric surgical procedures and to compare this between the 3 most frequent current surgical procedures (sleeve, gastric bypass, gastric banding).

STUDY DESIGN

Nationwide observational cohort study using data from French Hospital Information System (2013-2015) to evaluate incidence and severity of reoperations within 6 months after bariatric surgery. Hazard ratios (HR) of longitudinal comparison between historical propensity-matched cohorts were estimated from a Fine and Gray's model using competing risk of death.

RESULTS

Cumulative reoperation rates increased from postoperative day-30 to day-180. Consequently, 31.1 to 90.0% of procedures would have been missed if the reoperation rate was based solely on a 30-day follow-up. Reoperation rate at 6 months was significantly higher after gastric bypass than after sleeve (HR 0.64; IC 95% [0.53-0.77]) and corresponded to moderate-risk reoperations (HR 0.65; IC 95% [0.53-0.78]). Reoperation rate at 6 months was significantly higher after gastric banding than after sleeve (HR 0.08; IC 95% [0.07-0.09]) and corresponded to moderate-risk reoperations (HR 0.08; IC 95% [0.07-0.10]).

CONCLUSION

Cumulative incidence of reoperations increased from 30 days to 6 months after sleeve, gastric bypass, or gastric banding and corresponded to moderate-risk surgical procedures. Consequently, 30-day reoperation rate should no longer be considered when evaluating complications and surgical performance after bariatric surgery.

Adrenalectomy Risk Score: An Original Preoperative Surgical Scoring System to Reduce Mortality and Morbidity After Adrenalectomy

OBJECTIVE

To explore the determinants of postoperative outcomes of adrenal surgery in order to build a proposition for healthcare improvement.

SUMMARY OF BACKGROUND DATA

Adrenalectomy is the recommended treatment for many benign and malignant adrenal diseases. Postoperative outcomes vary widely in the literature and their determinants remain ill-defined.

METHODS

We based this retrospective cohort study on the "Programme de médicalisation des systèmes d'information" (PMSI), a national database that compiles discharge abstracts for every admission to French acute health care facilities. Diagnoses identified during the admission were coded according to the French adaptation of the 10th edition of the International Classification of Diseases (ICD-10). PMSI abstracts for all patients discharged between January 2012 and December 2017 were extracted. We built an Adrenalectomy-risk score (ARS) from logistic regression and calculated operative volume and ARS thresholds defining high-volume centers and high-risk patients with the CHAID method.

RESULTS

During the 6-year period of the study, 9820 patients (age: 55 ± 14; F/M = 1.1) were operated upon for adrenal disease. The global 90-day mortality rate was 1.5% (n = 147). In multivariate analysis, postoperative mortality was independently associated with age ≥75 years [odds ratio (OR): 5.3; P < 0.001], malignancy (OR: 2.5; P < 0.001), Charlson score ≥2 (OR: 3.6; P < 0.001), open procedure (OR: 3.2; P < 0.001), reoperation (OR: 4.5; P < 0.001), and low hospital caseload (OR: 1.8; P = 0.010). We determined that a caseload of 32 patients/year was the best threshold to define high-volume centers and 20 ARS points the best threshold to define high-risk patients.

CONCLUSION

High-risk patients should be referred to high-volume centers for adrenal surgery.

Variation in Bariatric Surgery Costs and Complication Rates in the Military Health System

Introduction: Within the Military Health System (MHS), facilities have struggled to meet minimum recommended volume thresholds for certain procedures. Understanding variations in complication rates and cost can help policymakers tailor policy to target improvement. Our objective was to quantify the variation in bariatric surgery complication rates and costs across a sample of military hospitals. Materials and Methods: We study a retrospective cohort of 38 military surgeons practicing in 21 military treatment facilities from 2007 to 2014 who performed 1,277 bariatric surgeries. Data from the Centralized Credentials and Quality Assurance System, which provides education and training characteristics of physicians, were linked to patient encounter data from the MHS Data Repository. Physicians were included if they performed at least five bariatric surgeries over the study period. Patients were included if they had a diagnosis of obesity (body mass index &gt; 30) and underwent a bariatric weight loss surgery. We calculated and summarized inpatient costs and complication rates across both surgeons and facilities using multivariable mixed-effects linear or logistic models. We used these models to calculate adjusted complication rates and average costs across both providers and hospitals to characterize variation in bariatric outcomes within the MHS. This study was considered exempt by the Uniformed Services University Institutional Review Board. Results: We find evidence of large variations in both complication rates and costs per admission. Overall, we found a 15.5% complication rate across the sample. When comparing averages across facilities, we find large variation in complications (49.4% coefficient of variation [CV]) and procedure costs (25.9% CV). Controlling for patient comorbidities, BMI, and year attenuates much of the variation (12.6% CV complications, 4.4% CV cost), but cannot completely explain differences across facilities. Our model suggests that complications cost 32% more than complication-free surgeries on average suggesting that quality improvement efforts could potentially yield large savings. Conclusions: We find large variations in complication rates even after controlling for patient health. Furthermore, surgical complications are a significant determinant of cost. Policymakers should target efforts to improve surgical quality across facilities and physicians. Surgical quality improvement initiatives could produce savings to the MHS through reduced complications and improved surgical readiness.

Association Between Hospitals' Risk-Adjusted Emergency Department Visits and Survival and Costs in Kidney Cancer Patients Undergoing Nephrectomy

PURPOSE

To estimate the association between a hospital's risk-adjusted emergency department (ED) visit rate and its risk-adjusted mortality rate and costs among kidney cancer patients undergoing initial nephrectomy.

PATIENTS AND METHODS

Using 2007-2012 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we used logistic regression to model ED visit occurrence within 30 and 365 days for all kidney cancer patients receiving initial surgery. Our model controlled for demographics, stage, histology, systemic targeted therapy, and comorbidities. Based on model predictions, we created a ratio of actual versus predicted ED visits for hospitals to identify hospitals with higher and lower than predicted ED visit rates. We estimated the association between the hospitals' ED visit ratio and hospitals' risk-adjusted 365-day mortality rates, and 6- and 12-month total costs and total costs (less ED visits).

RESULTS

In our sample of 6078 patients, 15.5% had an ED visit within 30 days of surgery and 43.5% within 365 days. For hospitals with ≥ 11 patients, we found no statistically significant association between 30-day or 365-day risk-adjusted ED visit rate and their 365-day risk-adjusted mortality rate. Hospitals' 30-day ED visit rates were not significantly associated with either 6- or 12-month costs. However, hospitals' 365-day ED visit rates were significantly associated with 12-month costs, even when excluding the cost of the ED visit.

CONCLUSION

Our results suggest hospitals' risk-adjusted ED visit rates capture a qualitatively different measure of quality than the more commonly reported mortality rates. Longer term ED visit rates are significantly associated with increased costs while 30-day ED visits are not.

Health Care Policy and Outcomes after Colon and Rectal Surgery: What Is the Bigger Picture?-Cost Containment, Incentivizing Value, Transparency, and Centers of Excellence

Early in the 21st century, the costs of health care in the United States have spiraled out of control, where the per capita spending is $9,237 per person-the highest in the world. By 2020, an estimated 20% of GDP will be spent on health care. The issue of cost and quality is now becoming a national crisis, with ∼50% of hospitals losing money on clinical operations, forcing closure of essential critical access hospitals, and forcing health care workers to relocate or change professions. This crisis will only worsen with the graying of America, as an estimated 17% of Americans will be over the age of 65 years by the year 2020. The policy and financial structures on which these changes are based are important factors of which practicing surgeons should be aware. This review discusses recent national health care policy reform and specific topics including cost-containment legislation, value-based incentives and penalties, transparency, and centers of excellence in colorectal surgery.

Variation in Outcomes at Bariatric Surgery Centers of Excellence

Importance

In the United States, reports about perioperative complications associated with bariatric surgery led to the establishment of accreditation criteria for bariatric centers of excellence and many bariatric centers obtaining accreditation. Currently, most bariatric procedures occur at these centers, but to what extent they uniformly provide high-quality care remains unknown.

Objective

To describe the variation in surgical outcomes across bariatric centers of excellence and the geographic availability of high-quality centers.

Design, Setting, and Participants

This retrospective review analyzed the claims data of 145 527 patients who underwent bariatric surgery at bariatric centers of excellence between January 1, 2010, and December 31, 2013. Data were obtained from the Healthcare Cost and Utilization Project's State Inpatient Database. This database included unique hospital identification numbers in 12 states (Arkansas, Arizona, Florida, Iowa, Massachusetts, Maryland, North Carolina, Nebraska, New Jersey, New York, Washington, and Wisconsin), allowing comparisons among 165 centers of excellence located in those states. Participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Those included in the study cohort were patients with a primary diagnosis of morbid obesity and who underwent laparoscopic Roux-en-Y gastric bypass, open Roux-en-Y gastric bypass, laparoscopic gastric band placement, or laparoscopic sleeve gastrectomy. Excluded from the cohort were patients younger than 18 years or who had an abdominal malignant neoplasm. Data were analyzed July 1, 2016, through January 10, 2017.

Main Outcomes and Measures

Risk-adjusted and reliability-adjusted serious complication rates within 30 days of the index operation were calculated for each center. Centers were stratified by geographic location and operative volume.

Results

In this analysis of claims data from 145 527 patients, wide variation in quality was found across 165 bariatric centers of excellence, both nationwide and statewide. At the national level, the risk-adjusted and reliability-adjusted serious complication rates at each center varied 17-fold, ranging from 0.6% to 10.3%. At the state level, variation ranged from 2.1-fold (Wisconsin decile range, 1.5%-3.3%) to 9.5-fold (Nebraska decile range, 1.0%-10.3%). After dividing hospitals into quintiles of quality on the basis of their adjusted complication rates, 38 of 132 (28.8%) had a center in a higher quintile of quality located within the same hospital service area. Variation in rates of complications existed at centers with low volume (annual mean [SD] procedure volume, 156 [20] patients; complication range, 0.6%-6.4%; 9.8-fold variation), medium volume (annual mean [SD] procedure volume, 239 [27] patients; complication range, 0.6%-10.3%; 17.5-fold variation), and high volume (annual mean [SD] procedure volume, 448 [131] patients; complication range, 0.6%-4.9%; 7.5-fold variation).

Conclusions and Relevance

Even among accredited bariatric surgery centers, wide variation exists in rates of postoperative serious complications across geographic location and operative volumes. Given that a large proportion of centers are geographically located near higher-performing centers, opportunities for improvement through regional collaboratives or selective referral should be considered.

Meaningful Thresholds for the Volume-Outcome Relationship in Total Knee Arthroplasty

BACKGROUND

Increasing evidence supports the finding that patients undergoing a total knee arthroplasty with high-volume physicians and hospitals achieve better outcomes. Unfortunately, the existing definitions for high-volume surgeons and hospitals are highly variable and entirely arbitrary. The aim of this study was to identify a set of meaningful hospital and surgeon total knee arthroplasty volume thresholds.

METHODS

Using 289,976 patients undergoing primary total knee arthroplasty from an administrative database, we applied stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve to generate sets of volume thresholds most predictive of adverse outcomes. The outcomes considered for surgeon volume included 90-day complication and 2-year revision. For hospital volume, we considered 90-day complications and 90-day mortality.

RESULTS

SSLR analysis of the ROC curves for 90-day complication and 2-year revision rates by surgeon volume identified four volume categories: 0 to 12, 13 to 59, 60 to 145, and ≥146 total knee arthroplasties per year. Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories. Revision rates followed a similar pattern, but did not decrease between surgeons performing 60 to 145 arthroplasties per year and those performing ≥146 arthroplasties per year. SSLR analysis of 90-day complication and 90-day mortality rates by hospital volume also identified four volume categories: 0 to 89, 90 to 235, 236 to 644, and ≥645 total knee arthroplasties per year. Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories, but the rates did not decrease between hospitals performing 236 to 644 arthroplasties per year and those performing ≥645 arthroplasties per year. Mortality rates for hospitals with ≥645 total knee arthroplasties per year were significantly lower (p < 0.05) than those below the threshold.

CONCLUSIONS

Our study supports the use of SSLR analysis of ROC curves for risk-based volume stratification in total knee arthroplasty volume-outcomes research. SSLR analysis established meaningful volume definitions for low, medium, high, and very high-volume total knee arthroplasty surgeons and hospitals. This should help patients, surgeons, hospitals, and policymakers to make decisions with regard to the optimal delivery of total knee arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of a National Bariatric Surgery Center of Excellence Program on Medicare Expenditures

INTRODUCTION

In 2006, the Centers for Medicare and Medicaid Services (CMS) issued a national coverage decision restricting bariatric surgery to designated centers of excellence (COE). Although prior studies show mixed results on complications and reoperations, no prior studies evaluated whether this policy reduced spending for bariatric surgery. We sought to determine whether the coverage restriction to COE-designated hospitals was associated with lower payments from CMS.

METHODS

We utilized national Medicare claims data to examine 30-day episode payments for patients who underwent bariatric surgery from 2003 to 2010 (n = 72,117 patients). We performed an interrupted time series analysis, adjusting for patient factors, preexisting temporal trends, and changes in procedure type, to determine whether the 2006 coverage decision was associated with lower Medicare payments above and beyond any existing secular trends. For these analyses, we included payments for the index hospitalization, readmissions, physician services, and post-discharge ancillary care.

RESULTS

After accounting for patient factors, preexisting temporal trends, and changes in procedure type, there were no statistically significant improvements in episode payments after (US$14,720) vs before (US$14,283) the coverage decision (+US$437, 95% CI, -US$10 to +US$883). In a direct assessment of payments for COE-designated hospitals (US$14,481) vs. non-COE-designated hospitals (US$14,756), no significant differences in episode payments were found (-US$275, 95% CI, -US$696 to +US$145).

CONCLUSIONS

We found no significant reductions in 30-day episode payments after vs before restricting coverage to COE-designated hospitals. Center of excellence status is not a proxy for savings to the healthcare system.

Hospital variation in rates of acid-reducing medication use after laparoscopic sleeve gastrectomy

BACKGROUND

Postoperative gastroesophageal reflux is one of the most important long-term complications of sleeve gastrectomy, the most common bariatric procedure.

OBJECTIVE

To assess variation in hospital performance with laparoscopic sleeve gastrectomy using rates of acid-reducing medication use at postoperative 1 year.

SETTING

Clinical registry of bariatric surgical patients at academic and community hospitals in Michigan.

METHODS

We studied 2923 patients who underwent laparoscopic sleeve gastrectomy across 39 hospitals in the Michigan Bariatric Surgery Collaborative, 2007 to 2014. We compared risk- and reliability-adjusted rates of new-onset reflux-defined by new use of acid-reducing medication-across hospitals and in relation to surgical quality indicators (hospital procedure volume and 30-day complications).

RESULTS

Overall, 20% of patients were newly taking acid-reducing medication at postoperative 1 year. Hospital rates of new medication use varied 3-fold, ranging from 10% (95% CI 7-15%) to 31% (95% CI 23-40%) of patients. Of the 2 hospitals with significantly lower rates of new medication use, 1 was high volume and 1 was medium volume. The 1 hospital with significantly higher rates was medium volume. Rates of acid-reducing medication use did not correlate with hospital volume or perioperative complications.

CONCLUSION

Across Michigan hospitals, rates of new acid-reducing medication use at 1 year after laparoscopic sleeve gastrectomy varied widely and did not correlate with traditional quality indicators. Future research could explore differences in surgical technique to better understand the factors underlying variation in long-term outcomes after sleeve gastrectomy.

Hospital variation in perioperative complications for laparoscopic sleeve gastrectomy in Michigan

BACKGROUND

Laparoscopic sleeve gastrectomy has surpassed gastric bypass and laparoscopic adjustable gastric banding recently as the most common weight-loss procedure. Previously, substantial concerns existed regarding variation in perioperative safety with bariatric surgery. This study aimed to assess rates of perioperative complications for laparoscopic sleeve gastrectomy across hospitals and in relation to procedure volume within the Michigan Bariatric Surgery Collaborative.

STUDY DESIGN

We analyzed 8,693 patients who underwent laparoscopic sleeve gastrectomy from 2013 through 2014 across 40 hospitals in the Michigan Bariatric Surgery Collaborative. Mixed-effects logistic regression was used to assess hospital variation in risk- and reliability-adjusted rates of overall and serious 30-day complications and their relationship with hospital annual volume of stapling procedures (gastric bypass and sleeve gastrectomy).

RESULTS

Overall, 5.4% of patients experienced perioperative complications. Adjusted rates of overall complications varied three-fold across hospitals, ranging from 3.6% (95% confidence interval 1.9-6.8%) to 11.0% (95% confidence interval 7.7-15.5%). Serious complications occurred in just 1.2% of patients and varied minimally. In this analysis, hospital volume was not associated with overall or serious complications. The 1 hospital with significantly less overall complication rates was high-volume (≥ 125 procedures/year); however, of the 4 hospitals with significantly greater complication rates, 3 were medium-volume (50-124 procedures/year), and 1 was high-volume. The remaining hospitals were not significantly different than the cohort mean.

CONCLUSION

Serious complications among patients undergoing laparoscopic sleeve gastrectomy were relatively infrequent in this cohort of patients in the Michigan Bariatric Surgery Collaborative. Rates of overall complications varied widely across the hospitals enrolled in this statewide quality collaborative, although this variation was unrelated to volume standards required for accreditation as a comprehensive bariatric surgery center.

Pancreatic Resection Results in a Statewide Surgical Collaborative

BACKGROUND

A strong relationship between hospital caseload and adverse outcomes has been demonstrated for pancreatic resections. Participation in regional surgical collaboratives may mitigate this phenomenon. This study sought to investigate changes over time in adverse outcomes after pancreatectomy across hospitals with different caseloads in a statewide surgical collaborative.

METHODS

The study investigated patients undergoing pancreatic resection from January 2008 to August 2013 at Michigan Surgical Quality Collaborative (MSQC) hospitals (1007 patients in 19 academic and community hospitals). Risk-adjusted rates of major complications, mortality, and failure to rescue were compared between hospitals based on caseloads (low, medium, and high) in early (2008-2010) and later (2011-2013) periods. Finally, the degree to which different complications explained changes in hospital outcome variation was assessed.

RESULTS

Adjusted rates of major complications and mortality decreased over time, driven largely by improvements at low-caseload hospitals. In 2008-2010, risk-adjusted major complication rates were higher for low-caseload than for high-caseload hospitals (27.8 vs. 17.8 %; p = 0.02). However, these differences were attenuated in 2011-2013 (22.2 vs. 20.0 %; p = 0.74). Similarly, adjusted mortality rates were higher in low-caseload hospitals in 2008-2010 (6.2 vs. 0.8 %; p = 0.02), but these differences were attenuated in 2011-2013 (3.3 vs. 1.1 %; p = 0.18). Variation in major complications decreased, largely due to decreased variation in "medical" complication rates, with less change in surgical-site complications.

CONCLUSION

Participation in regional quality collaboratives by lower-volume hospitals can attenuate the volume-outcome relationship for pancreatic surgery. Continued work in collaboratives with an emphasis on technical and intraoperative aspects of care may improve overall quality of care.

Hospital volume and outcomes for laparoscopic gastric bypass and adjustable gastric banding in the modern era

BACKGROUND

Over the past decade, there has been a rapid decline in adverse events after bariatric surgery. As a result, it is possible that the influence of hospital volume on outcomes has attenuated over time. The objective of the present study was to examine whether the relationship between hospital volume and adverse events has persisted in the era of laparoscopic surgery. This study is based on analysis of State Inpatient Databases (SID) for 12 states from 2006 through 2011, which included 446,127 patients.

METHODS

Using hospital discharge data, changes in serious complications, reoperations and mortality over time, and the impact of hospital volume on outcomes among patients undergoing laparoscopic adjustable gastric band (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) were studied. Hospitals were stratified by operative volume, and using multivariable logistic regression to adjust for patient characteristics and procedure-type, the relationships between hospital volume and outcomes during 3 2-year periods were examined: 2006-2007, 2008-2009, and 2010-2011.

RESULTS

The rate of reoperations and mortality were low, and there were no significant differences between the highest (>125 cases/yr) and lowest (<50 cases/yr) volume hospitals for both LAGB and LRYGB. The volume-outcome relationship was most prominent when examining rates of adjusted odds ratios for serious complications at the lowest volume hospitals compared with the highest volume hospitals (LAGB: 1.65 [CI: 1.18, 2.30] for 2006-2007, 1.81 [CI: 1.36, 2.41] for 2008-2009, and 2.08 [CI:1.40, 3.09] for 2010-2011; LRYGB: 1.55 [CI:1.23, 1.95] for 2006-2007, 1.39 [CI:1.09, 1.76], and 1.39 [CI:1.07, 1.80] for 2010-2011).

CONCLUSIONS

Outcomes improved over the study period at both high- and low-volume volume hospitals. There remain significant differences in serious complications between the highest and lowest volume hospitals for both stapled and nonstapled procedures.

Changing trends in bariatric surgery

BACKGROUND AND AIMS

Bariatric surgery is considered the only long-lasting treatment for morbid obesity. Techniques and procedures have changed dramatically. We report on some of the major changes in the field.

MATERIALS AND METHODS

We reviewed some of the major changes in trends in bariatric surgery based on some landmark paper published in the literature.

RESULTS

We identified three major phases in the evolution of bariatric surgery. The pioneer phase was mostly characterized by discovery of weight loss procedures serendipitously from procedures done for other purposes. The second phase can be identified with the advent of laparoscopic techniques. This is considered the phase of greatest expansion of bariatric surgery. The metabolic phase derives from the improved understanding of the mechanisms of actions of the bariatric operations at the hormonal and molecular level.

CONCLUSIONS

Bariatric surgery has changed significantly over the years. The safety of the laparoscopic approach, along with the better understanding of the metabolic changes obtained postoperatively, has led to a more individualized approach and also an attempt to expand the indications for these procedures.

Reliability of surgical outcomes for predicting future hospital performance

BACKGROUND

Because of small sample sizes and low event rates, risk-adjusted surgical outcomes often do not meet reliability benchmarks for distinguishing hospital performance. Nonetheless, it is unclear whether these measures may still be useful for predicting future hospital surgical performance.

METHODS

We used national Medicare data to analyze patients undergoing colectomy from 2007 to 2010 (n=462,959 patients). We first quantified 2007-2008 outcome reliability (ability to differentiate quality differences) and ranked hospitals based on their 2007-2008 risk-adjusted outcome rates. To assess the ability of adjusted outcomes to predict true performance, we evaluated future (2009-2010) outcomes across quintiles of past performance. We then systematically sampled 2007-2008 cases to evaluate performance prediction when hospitals' past performance was measured with progressively lower reliability levels.

RESULTS

Outcomes in 2007-2008 were good predictors of outcomes in the next 2 years (2009-2010), but predictive strength depended upon reliability. With progressive sampling of 2007-2008 caseloads, outcome reliability and predictive strength decreased. With 100% sampling of 2007-2008 caseloads, the worst versus best hospital quintile based on past performance had 1.52 [95% confidence interval (CI), 1.44-1.60] times the odds of mortality and 1.50 (95% CI, 1.44-1.56) times the odds of complications in 2009-2010. With 10% sampling, outcome reliability was well below commonly accepted benchmarks, but the worst quintile of hospitals in 2007-2008 still had 1.12 (95% CI, 1.06-1.19) times the odds of mortality and 1.16 (95% CI, 1.11-1.21) times the odds of complications in 2009-2010 compared with the best quintile of hospitals.

CONCLUSIONS

Even at very low reliability levels, risk-adjusted outcome measures may distinguish best and worst hospitals' surgical performance. This study suggests that commonly accepted reliability thresholds may be too high, especially in the context of selective referral.

Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence

IMPORTANCE

Starting in 2006, the Centers for Medicare & Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as centers of excellence (COE) by 2 major professional organizations.

OBJECTIVE

To evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients.

DESIGN, SETTING, AND PATIENTS

Retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states (n = 321,464 patients) of changes in outcomes in Medicare patients undergoing bariatric surgery (n = 6723 before and n = 15,854 after implementation of the policy). A difference-in-differences analytic approach was used to evaluate whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients (n = 95,558 before and n = 155,117 after implementation of the policy).

MAIN OUTCOME MEASURES

Risk-adjusted rates of any complication, serious complications, and reoperation.

RESULTS

Bariatric surgery outcomes improved during the study period in both Medicare and non-Medicare patients; however, this change was already under way prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs before) implementation of the CMS national coverage decision for any complication (8.0% after vs 7.0% before; relative risk [RR], 1.14 [95% CI, 0.95-1.33]), serious complications (3.3% vs 3.6%, respectively; RR, 0.92 [95% CI, 0.62-1.22]), and reoperation (1.0% vs 1.1%; RR, 0.90 [95% CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n = 179) vs hospitals without the COE designation (n = 519), no significant differences were found for any complication (5.5% vs 6.0%, respectively; RR, 0.98 [95% CI, 0.90-1.06]), serious complications (2.2% vs 2.5%; RR, 0.92 [95% CI, 0.84-1.00]), and reoperation (0.83% vs 0.96%; RR, 1.00 [95% CI, 0.86-1.17]).

CONCLUSIONS AND RELEVANCE

Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.

The impact of accreditation on safety and cost of bariatric surgery

BACKGROUND

The objective of this study was to examine how much of the impact of the Centers for Medicare and Medicaid Services' national coverage decision (NCD) on bariatric surgery was driven by the restriction of reimbursements to Centers of Excellence (COE). We used inpatient care data of those with employer-sponsored insurance plans across United States using the MarketScan Commercial Claims and Encounter Database (2003-2009).

METHODS

We performed a retrospective cohort study evaluating the impact of the accreditation on subjects with a difference-in-difference approach (removing the temporal changes occurring in non-COEs) on rates of inpatient mortality, 90-day reoperations, complications, readmissions, and total payments.

RESULTS

A total of 30,755 patients (43.9 ± 11.0 years; 79.9% women) had bariatric surgery. A total of 17,896 patients underwent procedures at sites that became COEs (8455 pre-NCD and 9441 post-NCD, [+10.4%]) compared with 12,859 at non-COEs (6534 pre-NCD and 6325 post-NCD, [-3.3%]). Of the total number of bariatric procedures, laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable band procedures increased from 42.9% and 3.1% pre-NCD to 64.5% and 19.7% post-NCD, respectively. In the COEs, there were reductions in inpatient mortality (.3% to .1%; P = .02), 90-day reoperations (.8% to .5%; P = .006), complications (36.4% to 27.6%; P<.001), and readmissions (10.8% to 8.8%; P<.001) while payments remained similar ($24,543 ± $40,145 to $24,510 ± $37,769; P = .9). After distinguishing from temporal trends and differences occurring at non-COEs, 90-day reoperation (-.8%; P = .02) and complication rates (-2.7%; P = .01) were lower at the COEs after the NCD.

CONCLUSIONS

The accreditation-based NCD in bariatric surgery was associated with lower rates of reoperations and complications. Such policies may become a powerful tool to improve surgical safety and quality.

The impact of hospital and surgeon volume on clinical outcome following bariatric surgery

The dramatic rise in the prevalence of obesity worldwide has led to the rapid growth of bariatric surgery. The aim of this pooled analysis is to evaluate the relationship between institutional and surgeon volume and outcomes following bariatric surgery. Medical, Embase, trial registries, conference proceedings and reference lists were searched for trials comparing clinical outcome following bariatric surgery at high and low volume hospitals and by high and low volume surgeons. Outcomes analysed were mortality, morbidity and length of hospital stay. Fifteen publications were included in this analysis. In total, 289,732 bariatric procedures were included in the institutional volume analysis, and 32,920 bariatric operations were included in the surgeon volume analysis. Mortality was reduced following surgery at high volume institutions (0.24 vs. 2.18 %; pooled odds ratio = 0.26; P = 0.004) and by high volume surgeons (0.41 vs. 2.77 %; pooled odds ratio = 0.21; P < 0.001). Similarly, morbidity was reduced in high volume institutions (7.84 vs. 8.85 %; pooled odds ratio = 0.52; P < 0.001) and with high volume surgeons (6.92 vs. 7.29 %; pooled odds ratio = 0.47; P < 0.001). There were insufficient data for conclusive statistical analysis of length of hospital stay. This pooled analysis does suggest a benefit in the centralisation of bariatric surgery to high volume institutions and surgeons with respect to mortality and morbidity. Future high-powered studies with adjustment for procedural and patient case mix are required to further define the volume-outcome relationship in bariatric surgery.

The use, safety and cost of bariatric surgery before and after Medicare's national coverage decision

OBJECTIVE

To determine the impact of the Centers for Medicare and Medicaid Services' (CMS) bariatric surgery national coverage decision (NCD) on the use, safety, and cost of care CMS beneficiaries.

BACKGROUND

In February 2006, the CMS issued a NCD restricting reimbursement for bariatric surgery to accredited centers and including coverage for laparoscopic adjustable gastric band (LAGB).

METHODS

A pre/postinterrupted time-series cohort study using nationwide Medicare data (2004-2008) evaluating rates of bariatric procedures/100,000 enrollees, 90-day mortality, readmission rate and payments.

RESULTS

Forty-seven thousand thirty patients underwent procedures at 928 sites pre-NCD and 662 post-NCD. The procedure rate/100,000 patients dropped after the NCD to 17.8 (from 21.9 in 2005) increasing to 23.8 and 29.1 in 2007 and 2008, respectively. Open roux-en-y gastric bypass (ORYGB) and laparoscopic roux-en-y gastric bypass (LRYGB) were common pre-NCD (56.0% ORYGB, 35.5% LRYGB) changing post-NCD with LAGB inclusion (12.8% ORYGB, 48.7% LRYGB, 36.7% LAGB). 90-day mortality pre-NCD was 1.5% (1.8% ORYGB, 1.1% LRYGB) and post-NCD was 0.7% (1.7% ORYGB, 0.8% LRYGB, 0.3% LAGB; P < 0.001). The 90-day rates of readmission decreased post-NCD (19.9% to 15.4%), reoperation (3.2% to 2.1%) and payments ($24,363 to $19,746; P for all <0.001). Differences in outcome and cost were largely explained by a shift in procedure type and patient characteristics.

CONCLUSIONS

The NCD was associated with a temporary reduction in procedure rate and a shift in types of procedures and patients undergoing bariatric surgery. It was associated with a significant decrease in the risk of death, complications, readmissions, and per patient payments.

Perioperative safety and volume: outcomes relationships in bariatric surgery: a study of 32,000 patients

BACKGROUND

Accreditation of Centers of Excellence in bariatric surgery requires a hospital volume of more than 125 procedures/year. There is no evidence-based rationale for this specific threshold. Our objective was to evaluate the contemporary perioperative safety of bariatric surgery and to characterize the relationship between volume and outcomes.

STUDY DESIGN

We queried the Nationwide Inpatient Sample 2005-2007 for open and laparoscopic bariatric procedures, complications, and death.

RESULTS

Thirty-two thousand five hundred and nine bariatric procedures were identified (21% open bypass [Open], 58% laparoscopic bypass [Lap], 21% laparoscopic gastric band [Band]). Inpatient overall mortality was low (total 0.12%, Open 0.3%, Lap 0.09%, Band 0.02%; p < 0.05 for all comparisons). Inpatient complications were more prevalent (total 3.9%, Open 5.9%, Lap 4%, Band 1.6%, p < 0.01 for all comparisons). For all 3 procedures, using a combined end point of mortality and major complications, a volume-outcomes relationship was evident for hospitals. This relationship appeared linear with no clear point that maximally differentiated high- and low-volume centers.

CONCLUSIONS

Using a nationwide dataset and bariatric procedure-specific data, we have demonstrated that bariatric surgery mortality and complication rates are very low. A definite volume-outcomes relationship exists when hospital-level data are analyzed, but there is no inflection point to justify selecting a specific volume threshold to determine Centers of Excellence. Low-volume centers with extremely low complication rates can be identified and, conversely, there are high-volume centers with elevated rates of complication.

Developing criteria for pediatric/adolescent bariatric surgery programs

The prevalence of morbid obesity in adolescents is rising at an alarming rate. Comorbidities known to predispose to cardiovascular disease are increasingly being diagnosed in these children. Bariatric surgery has become an acceptable treatment alternative for morbidly obese adults, and criteria have been developed to establish center-of-excellence designation for adult bariatric surgery programs. Evidence suggests that bariatric surgical procedures are being performed with increasing numbers in adolescents. We have examined and compiled the current expert recommendations for guidelines and criteria that are needed to deliver safe and effective bariatric surgical care to adolescents.

Comparison of right lobe donor hepatectomy with elective right hepatectomy for other causes in New York

INTRODUCTION

Right lobe donor hepatectomy (RLDH) is a potential source of liver allografts given the ongoing shortage of deceased donor organs available. Since there is no live donor registry in the United States, a population-based, unsolicited state-wide analysis has yet to be reported.

METHODS

The New York (NY) State Inpatient Database was used to query 1,524 elective liver lobectomies performed from 2001 to 2006. RLDH were identified in this cohort (n = 195; 13%). Most common indications for elective right lobe hepatectomy (ERH) were metastatic colon cancer (50%) and hepatocellular carcinoma (HCC) (34%). Primary outcomes were mortality, perioperative resources and major postoperative complications.

RESULTS

After a dramatic drop in 2002, there was a slow increase in RLDH from 2003 to 2006 in New York. Donors were younger (median age 36 vs. 60 years, P < 0.0001) and healthier (75% with no comorbidities vs. 18%, P < 0.0001) than patients undergoing ERH for other causes. Median length of hospital stay was 7 days in both groups. Donors were less likely to require blood transfusion (22.6 vs. 62.8%, P < 0.0001) and received less blood (mean 0.10 units vs. 2.4 units). Major post-operative complications based on the Clavien classification occurred in only 2.6% of donor cases compared to 13.8% in non-donors (P < 0.0001). There was one RLDH in-hospital mortality (0.5%) in New York compared to 4.3% after ERH (P = 0.003).

CONCLUSIONS

This study represents one of the first unsolicited regional analyses of donor morbidity and resource utilization for RLDH and further emphasizes the need and utility of a live donor registry.

How valid is the quantity and quality relationship in CABG surgery? A review of the literature

Numerous analyses have identified an inverse relationship between case volume in coronary artery bypass graft (CABG) surgery and mortality, and have led some to call for the consideration of minimum-volume standards for open-heart surgery programs. These findings, however, have been questioned by studies that demonstrate a weak or absent association, and by the availability of risk-adjusted mortality data. There is also growing evidence that clinical care processes have greater impact on mortality than sheer numbers alone. Policy decisions that may address this issue in the future need to consider the impact of mandating referrals away from low-volume programs, including the negative financial and programmatic effect on hospitals and both the clinical and social ramifications for patients and families, particularly in rural regions of the country.

Trends and outcomes of adolescent bariatric surgery in California, 2005-2007

OBJECTIVE

The goal of this study was to evaluate trends, and outcomes of adolescents who undergo bariatric surgery.

PATIENTS AND METHODS

Patients younger than 21 years who underwent elective bariatric surgery between 2005 and 2007 were identified from the California Office of Statewide Health Planning and Development database. Multivariate logistic regression was used to identify factors associated with the type of surgery.

RESULTS

Overall, 590 adolescents (aged 13-20 years) underwent bariatric surgery in 86 hospitals. White adolescents represented 28% of those who were overweight but accounted for 65% of the procedures. Rates of laparoscopic adjustable gastric banding (LAGB) increased 6.9-fold from 0.3 to 1.5 per 100,000 population (P<.01), whereas laparoscopic Roux-en-Y gastric bypass (LRYGB) rates decreased from 3.8 to 2.7 per 100 000 population (P<.01). Self-payers were more likely to undergo LAGB (relative risk [RR]: 3.51 [95% confidence interval: 2.11-5.32]) and less likely to undergo LRYGB (RR: 0.45 [95% confidence interval: 0.33-0.58]) compared with privately insured adolescents. The rate of major in-hospital complication was 1%, and no deaths were reported. Of the patients who received LAGB, 4.7% had band revision/removal. In contrast, 2.9% of those who received LRYGB required reoperations.

CONCLUSIONS

White adolescent girls disproportionately underwent bariatric surgery. Although LAGB has not been approved by the US Food and Drug Administration for use in children, its use has increased dramatically. There was a complication rate and no deaths. Long-term studies are needed to fully assess the efficacy, safety, and health care costs of these procedures in adolescents.

Association between ethnicity and prostate cancer outcomes across hospital and surgeon volume groups

OBJECTIVE

We analyzed the association between ethnicity and outcomes among prostate cancer patients across hospital and surgeon volume groups.

METHODS

In this retrospective cohort study using SEER-Medicare databases for the period between 1995 and 2003, prostate cancer cases were identified and retrospectively followed for one year pre- and up to eight years post-diagnosis. Based on volume, hospitals and surgeons were divided into three groups each. For each group, we fitted separate models to analyze the association between ethnicity and outcomes such as complications, eight-year mortality and cost, adjusting for covariates. Poisson (zero inflation), generalized linear model (log-link), and Cox regression models were used.

RESULTS

African American ethnicity was associated with 30-day complications among medium volume hospital group. African American patients receiving care at medium volume hospitals and from medium volume surgeons had higher costs. Hispanic patients receiving care at low and medium volume hospitals had lower cost compared to white patients. Hispanic patients receiving care from a high-volume surgeon experienced increased hazard of long-term mortality.

CONCLUSIONS

Association between ethnicity and outcomes varies across hospital and surgeon volume groups. Thus, volume based policy measures may need further exploration for understanding the interaction between structure, process, volume and outcomes.